Advanced Practice ProvidersFriend or Foe?
Frank Farkash, ACNP‐BCKettering Physician Network
Objectives
• Improve overall communication and collaboration between Physicians and APPs
• Increase knowledge about the APP educational process
• Explore current collaboration patterns• Describe current federal and state practice laws/limitations
About me
Acute care nurse practitionerJoined Kettering Network in January 2016Medical Observation and Critical Care
ER/Trauma nursing background, as well as pre‐hospital/firefighting volunteer work
Power of Perception
What are your perceptions?
“Effective collaboration among nurse practitioners and physicians requires appropriate sharing of information and mutual acknowledgment of and respect for each professional's knowledge, skills, and contributions to the provision of care.”
‐American College of Physicians, 2009
Who are “APPs”?
• Physician Assistant• Nurse Practitioner• Certified Registered Nurse Anesthetist• Clinical Nurse Specialist• Certified Nurse Midwife
“APRN” is blanket term for all nursing based APPs
A little history…
• First PA class started in 1965, Duke University Medical Center
• Consisted of 4 Naval Corpsmen• First Nurse Practitioner program developed in 1965 at the University of Colorado
• Approximately 15,000 NPs practicing in the U.S. by 1979
Physician Assistants Nationwide
• As of January 2016 there were 108,000 licensed PAs in the U.S.
• Certified to prescribe in all 50 states• Approximately 75,000 certified PAs in 2009, rapidly growing profession
Source: American Academy of Physician Assistants
Nurse Practitioners Nationwide
• Currently over 222,000 licensed NPs in the U.S.• NPs hold prescriptive privileges, including controlled substances in all 50 states (Schedule II limited in certain settings/states)
• Approximately 20,000 new NPs completed their academic programs in 2014‐2015
Source: American Association of Nurse Practitioners
Top Jobs for 20171. Dentist2. Nurse Practitioner 3. Physician Assistant 4. Statistician5. Orthodontist6. Nurse Anesthetist7. Pediatrician8. Computer Systems Analyst 9 (tie). Obstetrician and Gynecologist9 (tie). Oral and Maxillofacial Surgeon
Source: U.S. News and World Report
The Great Takeover…
...of increased access to care
NP vs. PA
• NP – graduate degree program (Masters or Doctoral)
• PA – Most are graduate programs, all must be by 2020
• NP: Undergraduate nursing degree required• PA: Any undergraduate degree plus core sciences and required healthcare experience (i.e. MA, EMT, Paramedic, medical corpsman, RN, Surgical tech, etc.)
NP vs. PA
• NP programs are based on the nursing educational model, builds on nursing experience
• PA programs are based on the medical education model
• 2000 clinical hours for PA programs, including surgery electives
• Average 600 clinical hours for NP• NP programs are more specialized (Family practice, acute care, pediatric, neonatal)
Continuing Education
• PA requires 100 hrs CME every 2 years• Recertification exam every 10 years (previously every 6 years)
• NP varies by certifying body• ANCC national certification requires 150 hrsCME every 5 years, 25 must be pharmacology
• Maintain certification by CME or by re‐taking exam every 5 years
Source: AAPA, American Nurses Credentialing Center
NP vs. PA
• In all states, PAs must have a supervising physician in order to practice, but not necessarily required to be on‐site
• 21 states allow for full practice authority for NPs, the rest require a collaborating/supervising physician
Supervising/Collaborating
• Physician must be same specialty as the APP • Requires a signed agreement between the APP and physician
• Hospital medical staff board must approve privileges for APP to practice in the facility
“Collaboration among physicians and nurse practitioners can occur during both face‐to‐face encounters and electronically through the use of technology, including telephone, e‐mail, telehealth, and electronic health records.”
American College of Physicians, ed. Nurse Practitioners in PrimaryCare (a policy monograph of the American College of Physicians).Philadelphia: ACP; 2009
Full Practice
• 21 states and D.C. currently allow for “full practice authority” of NPs
• NP may evaluate/treat/refer patients without physician oversight
• Emphasis is on increasing access to primary care services in underserved areas
• Dept of Veterans Affairs passed bill in 2016 to include NPs but not PAs, CRNAs
Source: American Association of Nurse Practitioners
Full Practice
• Physician assistants currently do not have full practice authority in any state
• A taskforce has been developed and supported by the AAPA to pursue full practice authority
Source: American Academy of Physician Assistants
American College of Physicians
“…While there are differences in the nature and extent of training of physicians and NPs, …the College acknowledges that NPs are health care professionals with the capability to provide important and critical access to primary care.”
American College of Physicians, ed. Nurse Practitioners in PrimaryCare (a policy monograph of the American College of Physicians).Philadelphia: ACP; 2009
Ohio Laws for NP
• NP is required to maintain a regulated collaborative agreement with a physician
• NP practice is regulated by the Board of Nursing
• Defined in law as Primary Care Providers
• NPs are authorized to refer to physical therapy• NPs are authorized to provide proof of disability for disabled parking
• NPs are authorized to sign Do Not Resuscitate orders
• NPs are not presently authorized to sign Death Certificates
Scope of practice
• NP and PA have same scope of practice per Ohio state regulations
• May perform procedures as allowed by hospital privileges and physician training/supervision
• This allows for increased team flexibility, access for patients, and increased revenue
• Varies greatly by setting/facility
APPs at Kettering Health Network
• 263 APRNs, 162 PAs within the entire KHN
• Kettering Physician Network employs 103 APPs– 2 Neonatal– 31 Primary care– 12 Trauma – 7 Hospital medicine – 51 other specialties (cardiology, GYN, oncology, etc)
APP practice models
• Individual model– APP expected to see large patient volumes– APP bills for their services– Collaborates with physician when needed– APP works to top of their training/scope of practice
– Example: Family medicine, urgent care
• Co‐Management model– Integrates the APP into the physician encounter– Allows physicians to see higher volume of patients– APP sees patient, completes HPI, PE, A/P, then presents to the physician
– Physician reviews chart, repeats elements of the visit
– Physician bills for the encounter– APP performs all further care coordination– Example: CDU here at KMC
• Rotational model– Patient is following plan of care that can be managed by the APP
– Typically seen in specialty practices– Initial eval by the physician, follow‐up visits with the APP
– If there is change in plan/needs, re‐eval by physician
– Both APP and physician bill for their respective encounter
– Example: Neurosurgery, cardiology
• Follow‐up model– Physician is fully scheduled with new patients– APP sees follow‐up patients– Unless acuity requires physician visit– APP serves as primary contact between visits– Both APP and physician bill for their respective encounter
– Example: some Primary Care clinics
• Leverage model– APP assists physician by performing tasks that allow for increased clinical volume
– Results in additional physician productivity– Physician bills for all services– Example: APP rounds on hospitalized patients, reviews/manages lab results
– Similar to co‐management but not much APP decision making
• Specialty Specific model– Productivity expectation of the APP is defined in advance
– APPs may bill for independent procedures– Examples: APPs may serve as surgical First Assist, managing surgical follow‐up, initiate pre‐procedure workup
Bottom Line
• APPs are a great way to improve access to quality care for patients
• Improve clinical volumes and quality• Doing so in a cost effective manner• Ability to bill independently • Can allow physician to focus on higher acuity patients without compromising others
So why are we in medicine?
Hospital Administration
Serving people
Medicine is about‐
Same Team• Goals are best accomplished as a team • Teamwork divides the task and multiplies the success
• Avoid the “silo effect”
• So how do we improve our teams?
collaborationkəˌlabəˈrāSH(ə)n
noun
1. the action of working with someone to produce or create something.
2. traitorous cooperation with an enemy.
Source‐ Google dictionary
competekəmˈpēt
Verb
To strive to gain or win something by defeating or establishing superiority over others who are trying to do the same.
Source‐ Google dictionary
The Trust FactorThis image cannot currently be displayed.
Remember that one time…
• We have all had bad experiences– Mechanic, plumber, police officer, fellow provider
• How do we rebuild that trust?
• Accountability is key on all sides
Same Team
Same Goal
collaborationkəˌlabəˈrāSH(ə)n
noun1. the action of working with someone to
produce or create something.Source‐ Google dictionary
What is that “something” for us?
Same Team
Same Goal
“Effective collaboration among nurse practitioners and physicians requires appropriate sharing of information and mutual acknowledgment of and respect for each professional's knowledge, skills, and contributions to the provision of care.”
‐American College of Physicians, 2009
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Thank you for your time!
@frankfarkash #FOAMed
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